A very brief overview of how primary care physicians and other health professionals can assess and take action on significant contributors to falls in their patients.

Postural Hypotension
Pills
Pain and Mobility

These “3 Ps” can act alone or in concert and can have profound effects on your patients’ quality of life, and increase their risk of hospitalization, or eventually placement in long term care, due to serious falls.

FALLS are THE leading cause of injury for seniors

33%

of older adults fall every year and can result in physical and psychological consequences including disability, chronic pain, loss of independence, depression, reduced quality of life and death

8%

of fall-related hospitalizations end in death

235,355

Emergency Department visits and fall-related hospitalizations in Canada in 2012-13

84,828

fall-related hospitalizations in Canada in 2012-13

Medications that cause increased risk of falls in seniors

Diuretics 7%
Anti-inflammatory drugs 21%
Blood pressure medication 24%
Sleeping pills (benzodiazepines) 47%
Antipsychotics 59%
Antidepressants 68%
Opioid painkillers 68%

Sources: Canadian Frailty Network,  de Jong et al. 2013, Huang et al. 2012, Kelly et al. 2003

Postural Hypotension (PH)

A sudden drop in your blood pressure when you stand up after lying down or sitting.

25%

One in four people over the age of 65 may have symptoms of PH.

Screening / Assessment

  1. Take blood pressure while person is lying down, sitting, standing.  Be familiar with appropriate BP targets for geriatric patients: the SBP treatment goal is a pressure level of <140 mmHg (Grade C). The DBP treatment goal is a pressure level of <90 mmHg (Grade A).
  2. Review medications which may contribute to postural hypotension including, for example: anti-hypertensives, anticholinergics, pain medications.

Intervention

  1. Consider adjustments to offending medications where appropriate, like dosage reductions, changes in administration timing or stopping.
  2. Treat underlying causes of or contributors to postural hypotension.
  3. Encourage patients to be educated in strategies they can use, including behavioural, non-pharmacological, exercise strategies.
  4. For all postural hypotension resources go to www.posturalhypotension.ca.

Pills

Medications, especially as patients get older, have a higher risk for side effects due to changes in the way that the body processes them.  Careful review of the impact of a patient’s medications on their risks for falls presents one of the most effective, proactive opportunities to prevent a fall that can contribute to a rapid decline in your patient, including fractures, hospitalization and placement in long term care.

Screening / Assessment

  1. Be familiar with medications most frequently associated with higher risk for falls, in particular: psychotropics, cardiovascular, analgesics, antidiabetics, anticonvulsants.  Identify potentially inappropriate medications in your frail patients using a tools such as the Beers criteria or STOPP criteria.
  2. Use this calculator to assess anticholinergic burden.

Intervention

Explore deprescribing of medications that cause:

  • Falls
  • Postural Hypotension
  •  Weight loss
  • Urinary Incontinence
As complexity increases, refer to:
  • Review www.deprescribing.org
  • Refer to Central Intake who can help determine the best service (Outreach Teams, Geriatric Day Hospitals, and GeriMedRisk)  to help you with deprescribing.

Pain & Mobility: Why it matters

Screening / Assessment

  1. Very simply walk with your patient to see if pain is impacting on mobility.
  2. If they are experiencing pain, obtaining a medication history (including OTCs, herbal, illicit, alcohol) is a crucial first step.  What they are using now (both regularly and as needed) and what has been tried in the past can help determine next steps.

Intervention

  • Consider non-pharmacological approaches including weight loss and referral to Physiotherapy to assess if can benefit from interventions like exercise programs or gait aids.
  • For localized pain, consider trying topical analgesics.
  • If patient requires oral or other systemically absorbed medications first try oral medications like regularly scheduled acetaminophen (up to 3gm per day) +/- NSAIDs if safe to use given other comorbidities.
  • If the above proves inadequate and narcotics are being considered, refer to guidelines for narcotic use in non-cancer related pain.
  • For significant pain or neuropathic pain suggesting nerve impingement consider utility of Xray, CT or MRI of area impacted to determine if can benefit from intra-articular injections or referral for assessment of joint replacement or other surgery.